HomeMy Public PortalAbout682688 Page 1 of 29 rev 11-21-13
THE METROPOLITAN ST. LOUIS SEWER DISTRICT
2350 Market Street
St. Louis, MO 63103
Attn: Purchasing Department
Amanda Cooper (314)768-6329
Or
Lisa Treat (314)768-6269 2013 - 2014 EXPERIENCE QUESTIONNAIRE (USED IN PRE-QUALIFYING BIDDERS ON CONSTRUCTION WORK)
___________________________________________________________
SUBMITTED BY (COMPANY)
___________________________________________________________
ADDRESS
___________________________________________________________
CITY, STATE, ZIP CODE
___________________________________________________________
DATE
___________________________________________________________
CONTACT NAME (FOR QUESTIONS) - TELEPHONE & FAX
TAX ID NUMBER
_____________________________________________________________
E-MAIL ADDRESS
Page 2 of 29 rev 11-21-13
PREQUALIFICATION CHECK LIST
Below is a checklist of required documentation
Signed application and boxes checked indicating type of work requested – (Page 9).
Signed Conflict of Interest Statement (Page 5).
Bonding capacity indicated (Page 10)
Equipment Sheet is complete (Page 24)
Affidavit is complete with Notary Seal (Page 25, 26, or 27), whichever is applicable.
Attach Certificate from the Secretary of State showing company is authorized to
transact business in the State of Missouri.
Attach ACCORD Certificate of Insurance with MSD as certificate holder.
Attach drain layers license for City of St. Louis and/or St. Louis County (required for
Sewer Construction and Deep Sewer Construction categories)
Demolition work for MSD within the City of St. Louis – attach certification for specific
classification.
o Class I – no building size restrictions.
o Class II Limited to buildings under 3 stories/50 feet high/50,000 square feet
area/200,000 cubic feet volume.
o Buildings under 1 ½ stories/10,000 cubic feet volume, with no basement, require
no demolition license.
o St. Louis County does not require license.
Page 3 of 29 rev 11-21-13
RULES AND REGULATIONS FOR PREQUALIFICATION OF CONTRACTORS
ON WORK LET BY CONTRACT WITH
THE METROPOLITAN ST. LOUIS SEWER DISTRICT
1. An applicant for pre-qualification must furnish, under oath, detailed information with
respect to its equipment, past record, personnel, and experience, together with other
information as is called for in this Experience Questionnaire.
2. For a contractor to bid on a project they must be prequalified prior to the bid being
opened.
3. Any combination of qualified or unqualified contractors bidding jointly becomes a new
contracting firm and it must be pre-qualified in accordance with these rules. All
applications shall be in writing and signed by the principal parties in the joint venture.
4. An Experience Questionnaire on forms furnished by the Purchasing Manager must be
filed BY October 1st of each year in order to renew pre-qualification. This form must be
completed in detail. The District may require any additional information deem ed
necessary for pre-qualification. Companies pre-qualified within 3 months prior to this
date will not need to submit a renewal application until O ctober 1st of the following
year.
5. No bidder will be pre-qualified unless its Experience Questionnaire indicates that it has
the experience, organization, and equipment, sufficient in the judgment of the District,
that it can satisfactorily execute its contracts and meet its obligations therein incurred.
6. The Financial Statement of the controlling individual or corporate owner of the
business shall be submitted; if in the opinion of the District it is required.
7. If any significant change occurs in the in formation included on the contractors’ pre-
qualification form, notice shall be given to the District immediately.
8. All Corporations must furnish a certificate from the Secretary of State showing that it is
authorized to transact business in the State of Missouri
9. A copy of your firm's Certificate of Insurance meeting the Districts coverages is
required.
10. A copy of the applicable drain layers license from the City and/or County of St. Louis is
required for Sewer Construction or Deep Sewer Construction.
11. Demolition work for MSD within the City of St. Louis – attach certification for specific
classification.
o Class I – no building size restrictions.
o Class II Limited to buildings under 3 stories/50 feet high/50,000 square feet
area/200,000 cubic feet volume.
o Buildings under 1 ½ stories/10,000 cubic feet volume, with no basement, require
no demolition license.
o St. Louis County does not require a license.
NOTE: It is important that the "work experience" section be completed and that it
contains projects of the type for which pre-qualification is being requested.
Pre-qualification will not be granted for types of work that you subcontract to
others.
Page 4 of 29 rev 11-21-13
IMPORTANT INFORMATION FOR PROSPECTIVE BIDDERS
1. CONTRACT DOCUMENTS
Contract documents include, but may not be limited to, the advertisement, Instructions
to Bidders, Proposal, General Specifications, Detailed Specifications, Agreement, Bond
Form, and Plans. The documents are available on and after the day advertisement is
published and will be available via MSD’s website at www.stlmsd.com. Look for a link
to “ELECTRONIC PLANROOM”. Plans and specifications are also available for
viewing or purchase at Cross Rhodes Reprographics located at 1710 Macklind Avenue,
St Louis MO 63110.
2. DEPOSIT FOR DOCUMENTS
The charge for contract documents is not refundable.
3. PREQUALIFICATION
Bidders not already pre-qualified may make application for pre-qualification to the
Purchasing Manager, The Metropolitan St. Louis Sewer District, 2350 Market Street, St.
Louis, MO 63103. A contractor must be pre-qualified prior to bids being opened.
4. SPECIAL PROVISIONS
Any special provisions or requirements concerning the work on any particular contract
will be noted in the contract documents or on the Plans.
5. MINIMUM WAGE AND EMPLOYMENT DISCRIMINATION
The minimum wage to be paid to all labor will be shown in the contract documents
where applicable. Prevailing rates of pay shall be paid to skilled and unskilled labor,
and there shall be no discrimination in the selection or employment of labor on account
of race, creed, or color.
6. PROPOSAL DEPOSIT
The Proposal shall be accompanied by a certified check or cashier's check drawn on a
bank or trust company located in either St. Louis City or County or by a bid bond issued
by a surety company satisfactory to the District and which is authorized to transact
business in Missouri.
7. RIGHT TO REJECT
The Metropolitan St. Louis Sewer District reserves the right to reject any and all bids
and to waive technicalities.
Page 5 of 29 rev 11-21-13
VENDOR’S CONFLICT OF INTEREST QUESTIONNAIRE
1. Name the individual or company requesting to do business with The Metropolitan
St. Louis Sewer District (MSD).
2. In the past two (2) years has the individual or company name in 1. above (or any
principal of such company, i.e. partner, officer, director, etc.) contributed cash or gifts
in excess of $200.00 in value in the aggregate in any calendar year to any of the
individuals or organizations listed on Attachment A hereto?
Yes No
If yes, describe in detail (date/amount/description).
1. In the past two (2) years, has the individual or company named in 1. above done
business with any person listed in Attachment and/or their respective companies.
Yes No
If yes, describe in detail (date/amount/description).
4. The undersigned certifies that the above information is true and correct to the
best of his or her knowledge and belief.
Dated this day of _________________. 20 _
Printed Name: _____
Title: _____
Company Name: _____
Signature: _____
Page 6 of 29 rev 11-21-13
ATTACHMENT A
Updated January 1, 2013
Attachment "A" contains a list of the MSD Trustees and their re spective employer,
MSD officers and Directors, and the organizations which each are individually
associated with, as applicable.
MSD BOARD OF TRUSTEES
Trustee/Director Name of Firm, Organization or Company Affiliation
Robert T. Berry American Public Works Association Member
American Society of Civil Engineers Member
Circle Club of St. Louis Member
Engineer’s Club of St. Louis Member
Engineers Without Borders Member
Huntbridge Forest Subdivision Secretary
Manchester UMC Board of Trustees Member
Masonic Lodge of Missouri Member
Missouri Athletic Club Member
Missouri Botanical Garden Member
Missouri Society of Professional Engineers Member
Missouri University of Science & Technology Adjunct Professor
Missouri University of Science & Technology Academy
of Civil Engineers
Member
Missouri University of Science & Technology Academy
of Miner Athletics
Member
Missouri University of Science & Technology Alumni
Association
Member, Executive
Committee
Moolah Shrine Temple Member
Professional Training for Engineers, LLC President
Racquet Ruckus Foundation Chairman
Reserve Officers Association Member
Scottish Rite Bodies Member
U.S. Army Reserves, Retired Retired Officer
Water Environment Federation Member
James H. Buford African American Jewish Task Force Member
Chancellors Council Advocacy Committee - University
Missouri-St. Louis
Board Member
Clear Channel Advisory Board Board Member
Commission on Human Rights Board Member
Confluence Academy Board and Grand Center Arts
Academy
Board Member
Fair St. Louis Board Member
Father Support Center Board Member
Fontbonne Council of Regents Member
Grand Center Arts District Past Chair and
Member
Greater St. Louis Area Council, Boy Scouts of America Board Member
Heat Up/Cool Down St. Louis Vice Chair
Immigration & Innovation Steering Committee Member
Jobs For America’s Graduates (JAG) Board Member
Mercantile Library Board of Direction Member
Midwest Health Initiative Board Board Member
Missouri State University Foundation Board Member
Norwood Hills Country Club Scholarship Committee Member
Rebuilding Together St. Louis Board Member
STL 250 Board Board Member
St. Louis Artist's Guild Member
Page 7 of 29 rev 11-21-13
MSD BOARD OF TRUSTEES
Trustee/Director Name of Firm, Organization or Company Affiliation
James H. Buford St. Louis Black Repertory Theatre Board Member
(cont'd.) St. Louis Black Leadership Roundtable Board Member
St. Louis ConnectCare Chairman
St. Louis Gateway Classic Sports Foundation Member
St. Louis Initiative to Reduce Violence (SIRV) Vice Chair
St. Louis Regional Health Commission Board Member
St. Louis Science Center Board of Trustees Trustee
St. Louis Zoo Board Member
The MUNY Board Member
The National Conference for Community & Justice
Regional Advisory Board
Board Member
US Bank Board Member
Workforce Investment Board of St. Louis County Board Member
John H. Goffstein Bartley Goffstein, LLC Member
Missouri Bar Association Member
St. Louis County Bar Association Member, Past
President
St. Louis Metropolitan Bar Association Member, former
Committee Chair
Temple Emanuel Member
Eddie Ross, Jr. None
Brian Hoelscher American Public Works Association Member
American Society of Civil Engineers Member
Engineers Club of St. Louis Member
Missouri Water Environment Association Member
Water Environment Federation Member
Annette K. Mandell Central West End Planning & Development
Committee
Member
Missouri Bar Association Member
USO Missouri Volunteer
West Point Parents Club Member
Barbara Mohn Water Wastewater CIO Forum Member
Susan M. Myers Association of Corporate Counsel Member
Bar Association of Metropolitan St. Louis Member
Missouri Bar Association Member
Brenda A. Schaefer Association of Financial Professionals Member
St. Louis Treasury Management Association Member
Government Finance Officers Association Member
Betsy Schubert Institute for Supply Management Member
Jonathon Sprague American Public Works Association (APWA) Member
American Water Works Association (AWWA) Member
Engineers Club of St. Louis Member
Missouri Water Environment Member
National Association of Clean Water Agencies
(NACWA)
Member
Water Environment Federation Member
Page 8 of 29 rev 11-21-13
MSD BOARD OF TRUSTEES
Trustee/Director Name of Firm, Organization or Company Affiliation
Vicki Taylor-Edwards AAIM Management Association Member
Certified Employee Benefits Association Member
Compensation Benefits Network Member
Human Resources Management Association Member
International Public Management Association Member
Michael E. Yates North County Labor Legislative Club Executive Board
Member
St. Louis Labor Council Delegate
Jan Zimmerman American Water Works Association Member
Government Finance Officers Association Member
National Association of Female Executives Member
National Association of Professional Women Member
Women in Public Finance Member
Page 9 of 29 rev 11-21-13
APPLICATION TO THE METROPOLITAN ST. LOUIS SEWER DISTRICT FOR
CERTIFICATE OF QUALIFICATION TO BID
The undersigned hereby applies to the Executive Director of the Metropolitan St. Louis Sewer District for a
Certificate of Qualification to bid the followin g types of work: (Check each type of work for which qualification is
requested)
________ Sewer Construction (Drain layers license required for City or County)
Section V. A., Page 12
________ Deep Sewer Construction (Drain layers license required for City or County)
Section V. B., Page 13
________ Building Construction
Section V. C., Page 14
________ Natural Channel Restoration and Bio-Retention
Section V. D., Page 15
________ Pipe and Manhole Rehabilitation
Section V. E., Page 16
Cured-In-Place Pipe (CIPP)
Section V. F, Page 17 & 18
Cured-In-Place Lateral Liner (CIPL)
Section V. G, Page 19 & 20
________ Concrete Channels, Walls and Structures
Section V. H., Page 21
________ Mechanical/Electrical/Plumbing
Section V. I., Page 22
________ Tunneling/Trenchless
Section V. J., Page 23
________ Demolition
Section V. K., Page 24 – Refer to page 24 for explanation of Class I & II
St. Louis County Demolition
St. Louis City – Class I and II
St. Louis City – Class II only
Note: Sewer Construction shall consist of sewer projects requiring excavation of approximately 20 feet or less in
depth and which do not require significant involvement with urban type features such as utilities,
structures, urban landscape, other features of an urban nature, or sig nificant amounts of classified
excavation.
Deep Sewer Construction shall consist of sewer projects requiring excavation of greater than
approximately 20 feet in depth and/or that requires significant involvement with trench bracing or urban
type features, or significant amounts of classified excavation. The District shall be the sole judge as to the
type of construction each project falls under.
TYPE OF ORGANIZATION (Check Applicable Category)
______ Corporation ______ Partnership ______ Sole Proprietorship ______ Joint Venture
_________________________________
(Firm Name)
_________________________________
(Firm Address)
_____________________________________________________________________
(Firm City, State, Zip Code)
By ___________________________________ Title _________________________
_________________________________(Signature)
Page 10 of 29 rev 11-21-13
THE SIGNATORY OF THIS QUESTIONNAIRE GUARANTEES
THE TRUTH AND ACCURACY OF ALL STATEMENTS AND OF
ALL ANSWERS TO INTERROGATORIES HEREINAFTER MADE
Please list any previous experience or projects your company has completed for each
category you are requesting approval for, and any references you can provide.
Name of Contractor _____________________________________________________
Principal Address _______________________________________________________
( ) A corporation
( ) A general co-partnership
( ) A limited co-partnership
( ) An individual
( ) Joint Venture
( ) MW BE (Minority or Woman Business Enterprise)
If MW BE, what is the name of the agency/organization that issued the
certification document.
_______________________________________________________________
Please attach a copy of your certification document to this application.
Incorporated or organized:
Date _______________________ State ______________________________________
Radius of operations: ______________________________________________________
Type of work done: ______________________________________________________
Work usually sublet:
Name of Bonding Company _______________________________________________
Total Bonding Capacity of Firm $__________________________________________
I. How many years have you operated under the above name:
(a) As general contractor _____________________________________________
(b) As subcontractor ______________________________________________
II. List other names under which you have operated:
Name of company _____________________________________________
Type of work done ______________________________________________
Operated during period ______________________________________________
Name of company ______________________________________________
Type of work done ______________________________________________
Operated during period _____________________________________________
Page 11 of 29 rev 11-21-13
III. List of all partners or officers: (Note: if partnership limited, explain and
please list full 100% ownership)
Name and title _________________________________________________
Address, City and State ____________________________________________
Fractional interest in firm or number of shares owned ______________________
Name and title ____________________________________________________
Address, City and State ____________________________________________
Fractional interest in firm or number of shares owned ______________________
Name and title ___________________________________________________
Address, City and State ____________________________________________
Fractional interest in firm or number of shares owned ______________________
IV. What is the construction experience of the principal individuals of your
organization? (This includes the job superintendent).
An individual’s name
Present position or office
Years of construction experience
Magnitude and type of work
An individual’s name
Present position or office
Years of construction experience
Magnitude and type of work
An individual’s name
Present position or office
Years of construction experience
Magnitude and type of work
SECTION V. A. Sewer Construction Page 12 rev 11/21/13
V. List all experience for the past five years in the following categories for which
you want to qualify.
SECTION A. - Sewer Construction (See definition on page 9)
(Includes storm sewer, sanitary sewers, and small pump stations)
1. Contract Amount __________________ When Completed __________________
Type of Project ______________________________________________________
Pipe size and length laid ______________________________________________
Location of Project
Name, Address & Phone
Number of Owner _________________________________________________
2. Contract Amount _________________ When Completed __________________
Type of Project ______________________________________________________
Pipe size and length laid ______________________________________________
Location of Project ____________________________________________________
Name, Address & Phone
Number of Owner ________________________________________________
3. Contract Amount __________________ When Completed __________________
Type of Project ______________________________________________________
Pipe size and length laid ______________________________________________
Location of Project____________________________________________________
Name, Address & Phone
Number of Owner _________________________________________________
4. Contract Amount _________________ When Completed ___________________
Type of Project_______________________________________________________
Pipe size and length laid ______________________________________________
Location of Project ____________________________________________________
Name, Address & Phone
Number of Owner _________________________________________________
SECTION V. B. Deep Sewer Construction Page 13 rev 11/21/13
List all experience for the past five years in the following categories for which you
want to qualify.
SECTION B. - Deep Sewer Construction (See definition Page 9)
(Includes sanitary sewer, storm sewer, and small pump stations)
1. Contract Amount ____________________ When Completed____________________
Type of Project ______________________________________________________
Pipe size, average depth and length laid _________________________________
Location of Project ___________________________________________________
Name, Address & Phone
Number of Owner _________________________________________________
2. Contract Amount ____________________ When Completed________________
Type of Project _______________________________________________________
Pipe size, average depth and length laid
Location of Project ____________________________________________________
Name, Address & Phone
Number of Owner _________________________________________________
3. Contract Amount _______________ When Completed
Type of Project ______________________________________________________
Pipe size, average depth and length laid
Location of Project ___________________________________________________
Name, Address & Phone
Number of Owner _________________________________________________
4. Contract Amount ____________________ When Completed________________
Type of Project ______________________________________________________
Pipe size, average depth and length laid
Location of Project ____________________________________________________
Name, Address & Phone
Number of Owner _________________________________________________
SECTION V. C. Building Construction Page 14 rev 11/21/13
List all experience for the past five years in the following categories for which you
want to qualify.
SECTION C - Building Construction
(Includes large pump stations, treatment plants, and operational facilities)
1. Contract Amount ___________________ When Completed _______________
Type of Project ___________________________________________________
Location of Project ___________________________________________________
Name, Address & Phone
Number of Owner ____________________________________________________
2. Contract Amount __________________ When Completed ___________________
Type of Project ___________________________________________________
Location of Project ___________________________________________________
Name, Address & Phone
Number of Owner ____________________________________________________
3. Contract Amount __________________ When Completed __________________
Type of Project ___________________________________________________
Location of Project ___________________________________________________
Name, Address & Phone
Number of Owner ____________________________________________________
4. Contract Amount __________________ When Completed ___________________
Type of Project ___________________________________________________
Location of Project ___________________________________________________
Name, Address & Phone
Number of Owner ___________________________________________________
5. Contract Amount __________________ When Completed ___________________
Type of Project ___________________________________________________
Location of Project ___________________________________________________
Name, Address & Phone
Number of Owner ____________________________________________________
SECTION V.D. Natural Channel Restoration
And Bio-Retention Page 15 rev 11/21/13
List all experience for the past five years in the following categories for which you
want to qualify.
SECTION D. Natural Channel Restoration and Bio-Retention
(Includes hard-armoring, permanent BMP’s and landscaping.)
1. Contract Amount _________________ When Completed
Type of Project ______________________________________________________
Location of Project ___________________________________________________
Name, Address & Phone
Number of Owner ___________________________________________________
2. Contract Amount ____________________ When Completed _________________
Type of Project ______________________________________________________
Location of Project ___________________________________________________
Name, Address & Phone
Number of Owner ___________________________________________________
3. Contract Amount ____________________ When Completed _________________
Type of Project ____________________________________________________
Location of Project ___________________________________________________
Name, Address & Phone
Number of Owner
4. Contract Amount ____________________ When Completed _________________
Type of Project ___________________________________________________
Location of Project ___________________________________________________
Name, Address & Phone
Number of Owner ___________________________________________________
5. Contract Amount __________________ When Completed ___________________
Type of Project ______________________________________________________
Location of Project __________________________________________________
Name, Address & Phone
Number of Owner __________________________________________________
SECTION V. E. Pipe and Manhole Rehabilitation Page 16 rev 11/21/13
List all experience for the past five years in the following categories for which you
want to qualify.
SECTION E. - Pipe and Manhole Rehabilitation (Give pipe sizes)
(Includes point repair, pipe bursting, slip lining, etc.)
1. Contract Amount ________________ When Completed
Type of Project __________________________________________________
Location of Project ___________________________________________________
Name, Address & Phone
Number of Owner ___________________________________________________
2. Contract Amount _________________ When Completed ____________________
Type of Project _______________________________________________________
Location of Project ____________________________________________________
Name, Address & Phone
Number of Owner ____________________________________________________
3. Contract Amount ____________________ When Completed _________________
Type of Project ____________________________________________________
Location of Project ____________________________________________________
Name, Address & Phone
Number of Owner
4. Contract Amount ____________________ When Completed _________________
Type of Project ____________________________________________________
Location of Project ____________________________________________________
Name, Address & Phone
Number of Owner ____________________________________________________
5. Contract Amount ____________________ When Completed _________________
Type of Project ____________________________________________________
Location of Project ____________________________________________________
Name, Address & Phone
Number of Owner ____________________________________________________
SECTION V. F. Cured-in-Place Pipe Page 17 rev 11/21/13
List all experience for the past five years in the following categories for which
you want to qualify.
SECTION F. – Cured-in-Place Pipe (CIPP)
Statement of Qualifications for Cured-in-Place Pipe
1. Project Name: _______________________________________________________
Contract Amount ________________ When Completed
Manufacturer of CIPP product ___________ Trade Name of CIPP product ________
Component materials of CIPP (i.e. non-woven polyester felt tube and epoxy vinyl
ester resin) _________________________________________________________
Installation Method: Invert: _____ Pull-In: _____
Installed Pipe Length: _____ Pipe Sizes: _____
Pipe Type: Gravity ____ Pressure _______
Project Owner: ______________________________________________________
Contact Name: ___________________________Contact No.:_________________
Relevant ASTM Specification:
ASTM F-1216____ ASTM F-1743 ____ Other (please specify) ___________
Lowest 3rd Party D790 Testing Results on Project:
Flexural Strength _____________ Flexural Modulus _________________
Tensile Strength _____________ (only applicable for pressure pipe)
2. Project Name: __________________________________________________
Contract Amount ________________ When Completed
Manufacturer of CIPP product ___________ Trade Name of CIPP product ________
Component materials of CIPP (i.e. non-woven polyester felt tube and epoxy vinyl
ester resin) _________________________________________________________
Installation Method: Invert: _____ Pull-In: _____
Length of Pipe Installed: _______ Pipe Size: _____________
Pipe Type: Gravity _______ Pressure _______
Project Owner: ______________________________________________________
Contact Name: ___________________________Contact No.:_________________
Relevant ASTM Specification:
ASTM F-1216____ ASTM F-1743 ____ Other (please specify) ___________
Lowest 3rd Party D790 Testing Results on Project:
Flexural Strength _____________ Flexural Modulus _________________
Tensile Strength _____________ (only applicable for pressure pipe)
SECTION V. F. Cured-in-Place Pipe Page 18 rev 11/21/13
SECTION F. – Cured-in-Place Pipe (CIPP)
Statement of Qualifications for Cured-in-Place Pipe
3. Project Name: __________________________________________________
Contract Amount ________________ When Completed
Manufacturer of CIPP product ___________ Trade Name of CIPP product ________
Component materials of CIPP (i.e. non-woven polyester felt tube and epoxy vinyl
ester resin) _________________________________________________________
Installation Method: Invert: _____ Pull-In: _____
Length of Pipe Installed: _______ Pipe Size: _____________
Pipe Type: Gravity _______ Pressure _______
Project Owner: ______________________________________________________
Contact Name: ___________________________Contact No.:_________________
Relevant ASTM Specification:
ASTM F-1216____ ASTM F-1743 ____ Other (please specify) ___________
Lowest 3rd Party D790 Testing Results on Project:
Flexural Strength _____________ Flexural Modulus _________________
Tensile Strength _____________ (only applicable for pressure pipe)
4. Project Name: __________________________________________________
Contract Amount ________________ When Completed
Manufacturer of CIPP product ___________ Trade Name of CIPP product ________
Component materials of CIPP (i.e. non-woven polyester felt tube and epoxy vinyl
ester resin) _________________________________________________________
Installation Method: Invert: _____ Pull-In: _____
Length of Pipe Installed: _______ Pipe Size: _____________
Pipe Type: Gravity _______ Pressure _______
Project Owner: ______________________________________________________
Contact Name: ___________________________Contact No.:_________________
Relevant ASTM Specification:
ASTM F-1216____ ASTM F-1743 ____ Other (please specify) ___________
Lowest 3rd Party D790 Testing Results on Project:
Flexural Strength _____________ Flexural Modulus _________________
Tensile Strength _____________ (only applicable for pressure pipe)
SECTION V. G. Cured-in-Place Lateral Liner Page 19 rev 11/21/13
List all experience for the past five years in the following categories for which you
want to qualify.
SECTION G. – Cured in Place Lateral Lining (CIPL)
Statement of Qualifications for cured-in-place lateral lining (includes cured-in-place lateral
connection repairs).
1. Project Name: _______________________________________________________
Contract Amount ________________ When Completed
Manufacturer of CIPL product ___________ Trade Name of CIPL product ________
Component materials of CIPL (i.e. non-woven polyester felt tube and epoxy vinyl
ester resin) _________________________________________________________
No. of Laterals Lined: ________ Total Length of Laterals Lined: __________
Manufacturer of Water Tight Seal (waterstop): ______________________________
Manufacturer of Lateral Connection Repair (LCR): __________________________
(Attach written documentation from manufacturer certifying that contractor is an approved
installer of their product).
No. of LCR’s Installed: __________
Project Owner: ______________________________________________________
Contact Name: ___________________________Contact No.:_________________
Relevant ASTM Specification:
Lowest Value of 3rd Party D790 Testing Results on Project:
Flexural Strength ____________ Flexural Modulus __________________
2. Project Name: _______________________________________________________
Contract Amount ________________ When Completed
Manufacturer of CIPL product ___________ Trade Name of CIPL product ________
Component materials of CIPL (i.e. non-woven polyester felt tube and epoxy vinyl
ester resin) _________________________________________________________
No. of Laterals Lined: ________ Total Length of Laterals Lined: __________
Manufacturer of Water Tight Seal (waterstop): ______________________________
Manufacturer of Lateral Connection Repair (LCR): __________________________
(Attach written documentation from manufacturer certifying that contractor is an approved
installer of their product).
No. of LCR’s Installed: __________
Project Owner: ______________________________________________________
Contact Name: ___________________________Contact No.:_________________
Relevant ASTM Specification:
Lowest Value of 3rd Party D790 Testing Results on Project:
Flexural Strength ____________ Flexural Modulus __________________
SECTION V. G. Cured-in-Place Lateral Liner Page 20 rev 11/21/13
SECTION G. – Cured in Place Lateral Lining (CIPL)
Statement of Qualifications for cured-in-place lateral lining (includes cured-in-place
lateral connection repairs).
3. Project Name: _______________________________________________________
Contract Amount ________________ When Completed
Manufacturer of CIPL product ___________ Trade Name of CIPL product ________
Component materials of CIPL (i.e. non-woven polyester felt tube and epoxy vinyl
ester resin) _________________________________________________________
No. of Laterals Lined: ________ Total Length of Laterals Lined: __________
Manufacturer of Water Tight Seal (waterstop): ______________________________
Manufacturer of Lateral Connection Repair (LCR): __________________________
(Attach written documentation from manufacturer certifying that contractor is an approved
installer of their product).
No. of LCR’s Installed: __________
Project Owner: ______________________________________________________
Contact Name: ___________________________Contact No.:_________________
Relevant ASTM Specification:
Lowest Value of 3rd Party D790 Testing Results on Project:
Flexural Strength ____________ Flexural Modulus __________________
4. Project Name: _______________________________________________________
Contract Amount ________________ When Completed
Manufacturer of CIPL product ___________ Trade Name of CIPL product ________
Component materials of CIPL (i.e. non-woven polyester felt tube and epoxy vinyl
ester resin) _________________________________________________________
No. of Laterals Lined: ________ Total Length of Laterals Lined: __________
Manufacturer of Water Tight Seal (waterstop): ______________________________
Manufacturer of Lateral Connection Repair (LCR): __________________________
(Attach written documentation from manufacturer certifying that contractor is an approved
installer of their product).
No. of LCR’s Installed: __________
Project Owner: ______________________________________________________
Contact Name: ___________________________Contact No.:_________________
Relevant ASTM Specification:
Lowest Value of 3rd Party D790 Testing Results on Project:
Flexural Strength ____________ Flexural Modulus __________________
SECTION V.H. - Concrete Channels, Walls, & Structures Page 21 rev 11/21/13
List all experience for the past five years in the following categories for which you
want to qualify.
SECTION H. - Concrete Channels, Walls & Structures
1. Contract Amount ______________ When Completed ________________________
Type of Project _______________________________________________________
Location of Project ________________________________________________
Name, Address & Phone
Number of Owner _____________________________________________________
2. Contract Amount ________________ When Completed ________________________
Type of Project _______________________________________________________
Location of Project _________________________________________________
Name, Address & Phone
Number of Owner _____________________________________________________
3. Contract Amount ________________ When Completed ________________________
Type of Project _______________________________________________________
Location of Project _________________________________________________
Name, Address & Phone
Number of Owner _____________________________________________________
4. Contract Amount ________________ When Completed ________________________
Type of Project _______________________________________________________
Location of Project _________________________________________________
Name, Address & Phone
Number of Owner _____________________________________________________
5. Contract Amount ___________________ When Completed _____________________
Type of Project _____________________________________________________
Location of Project _________________________________________________
Name, Address & Phone
Number of Owner _________________________________________________
SECTION V.I. Mechanical/Electrical/Plumbing Page 22 rev 11/21/13
List all experience for the past five years in the following categories for which you
want to qualify.
SECTION I. - Mechanical/Electrical/Plumbing
1. Contract Amount ______________ When Completed ________________________
Type of Project _______________________________________________________
Location of Project ________________________________________________
Name, Address & Phone
Number of Owner _____________________________________________________
2. Contract Amount ________________ When Completed ________________________
Type of Project _______________________________________________________
Location of Project _________________________________________________
Name, Address & Phone
Number of Owner _____________________________________________________
3. Contract Amount ________________ When Completed ________________________
Type of Project _______________________________________________________
Location of Project _________________________________________________
Name, Address & Phone
Number of Owner _____________________________________________________
4. Contract Amount ________________ When Completed ________________________
Type of Project _______________________________________________________
Location of Project _________________________________________________
Name, Address & Phone
Number of Owner _____________________________________________________
5. Contract Amount ___________________ When Completed _____________________
Type of Project _____________________________________________________
Location of Project _________________________________________________
Name, Address & Phone
Number of Owner _________________________________________________
SECTION V. J. – Tunneling/Trenchless Page 23 rev 11/21/13
List all experience for the past five years in the following categories for which
you want to qualify.
SECTION J. – Tunneling/Trenchless
1. Contract Amount ______________ When Completed ________________________
Type of Project _______________________________________________________
Location of Project ________________________________________________
Name, Address & Phone
Number of Owner _____________________________________________________
2. Contract Amount ________________ When Completed ________________________
Type of Project _______________________________________________________
Location of Project _________________________________________________
Name, Address & Phone
Number of Owner _____________________________________________________
3. Contract Amount ________________ When Completed ________________________
Type of Project _______________________________________________________
Location of Project _________________________________________________
Name, Address & Phone
Number of Owner _____________________________________________________
4. Contract Amount ________________ When Completed ________________________
Type of Project _______________________________________________________
Location of Project _________________________________________________
Name, Address & Phone
Number of Owner _____________________________________________________
5. Contract Amount ___________________ When Completed _____________________
Type of Project _____________________________________________________
Location of Project _________________________________________________
Name, Address & Phone
Number of Owner _________________________________________________
SECTION V K. Demolition Page 24 rev 11/21/13
List all experience for the past five years in the following categories for which
you want to qualify.
SECTION K. – Demolition
Demolition work for MSD within the City of St. Louis –attach certification for specific
classification. Class I–no building size restrictions. .Class II -limited to buildings under 3
stories/50 feet high/50,000 square feet area/200,000 cubic feet volume. .Buildings under 1
½ stories/10,000 cubic feet volume, with no basement, require no demolition license.
St. Louis County – does not require license.
1. Contract Amount ______________ When Completed ________________________
Type of Project _______________________________________________________
Location of Project ________________________________________________
Name, Address & Phone
Number of Owner _____________________________________________________
2. Contract Amount ________________ When Completed ________________________
Type of Project _______________________________________________________
Location of Project _________________________________________________
Name, Address & Phone
Number of Owner _____________________________________________________
3. Contract Amount ________________ When Completed ________________________
Type of Project _______________________________________________________
Location of Project _________________________________________________
Name, Address & Phone
Number of Owner _____________________________________________________
4. Contract Amount ________________ When Completed ________________________
Type of Project _______________________________________________________
Location of Project _________________________________________________
Name, Address & Phone
Number of Owner _____________________________________________________
5. Contract Amount ___________________ When Completed _____________________
Type of Project _____________________________________________________
Location of Project _________________________________________________
Name, Address & Phone
Number of Owner _________________________________________________
SECTION V I. & VII. Page 25 rev 11/21/13
List all experience for the past five years in the following categories for which
you want to qualify.
VI. What Sewer or Building projects is your organization now in process of
constructing?
1. Contract Amount ____________ Scheduled Completion Date _______________
Type of Project ___________________________________________________
Location of Project _______________________________________________
Name, Address & Phone
Number of Owner __________________________________________________
2. Contract Amount ________________ Scheduled Completion Date ____________
Type of Project ____________________________________________________
Location of Project __________________________________________________
Name, Address & Phone
Number of Owner _________________________________________________
3. Contract Amount ____________ Scheduled Completion Date _______________
Type of Project ___________________________________________________
Location of Project _______________________________________________
Name, Address & Phone
Number of Owner __________________________________________________
4. Contract Amount ________________ Scheduled Completion Date ____________
Type of Project ____________________________________________________
Location of Project _________________________________________________
Name, Address & Phone
Number of Owner _________________________________________________
NOTE: If more space is needed, attach additional sheets.
VII. Have you ever failed to complete any work awarded to you? (If so, explain)
____________________________________________________________________
SECTION - Equipment Page 26 rev 11/21/13
EQUIPMENT
(What equipment do you own that is available for proposed work?)
QUANTITY ITEM DESCRIPTION, SIZE,
CAPACITY, ETC
EQUIP
HOURS
CONDITION YEARS
OF
SERVICE
PRESENT
LOCATION
* Condition shall be graded as follows:
New under 12 months Over 12 months old Rebuilt
N-1 0-1 (Good) R-1
0-2 (Average) R-2
0-3 (Fair) R-3
0-4 (Poor) R-4 (Poor)
Page 27
AFFIDAVIT FOR INDIVIDUAL
State of ____________________)
) ss.
County of __________________ )
___________________________________________, being duly sworn, deposes and
says that the answers to the foregoing interrogatories are true, and that any depository,
vendor or other agency herein named is authorized to supply The Metropolitan St. Louis
Sewer District with any information necessary to verify this statement.
__________________________________
(Applicant sign here)
Sworn to before me, this _______________ day of ____________________, 20 _____.
_____________________________
Notary Public
(seal)
AFFIDAVIT FOR CO-PARTNERSHIP
State of _____________________)
) ss.
County of ___________________)
___________________________________, being duly sworn, deposes and says that
they are a member of the firm of ___________________________________ that they
are familiar with the books of said firm showing its financial condition; and that the
answers to the foregoing interrogatories are true, and that any depository, vendor or
other agency herein named is authorized to supply The Met ropolitan St. Louis Sewer
District with any information necessary to verify this statement.
________________________________
_________________________________
________________________________
(Members of firm, sign above)
Sworn to before me, this _______________ day of ____________________, 20____.
_____________________________
Notary Public
(seal)
AFFIDAVIT FOR CORPORATION
State of ______________________)
) ss.
County of ____________________ )
________________________________, being duly sworn, deposes and says that ___he
is ___________________________________________________________of the
_______________________________________________________________________
the corporation described in and which executed the foregoing statement that
____he is familiar with the books of the said corporation, showing its financial condition;
and that the answers of the foregoing interrogatories are true, and that any depository,
vendor or other agency herein named is authorized to supply The Metropolitan St. Louis
Sewer District with any information necessary to verify this statement.
________________________________
________________________________
Title
_______________________________
_______________________________
Title
Sworn to before me, this _______________ day of __________________, 20 _______.
_______________________________
Notary Public
(seal)